Counting up the chocolates

The Royal Cornwall Hospital Trust has recently told staff to count the numbers of boxes of chocolates they receive from patients in order to assess patient satisfaction.

No, it's not 1 April - unfortunately. These managers appear to be serious, but in doing so they have neatly illustrated the impossibility of measuring the quality of a professional unit using surrogate statistics.

Why can't the 'chocolate box index' be relied upon? To begin with, the number and size of gifts will depend upon patients' economic circumstances, plus social and ethnic considerations. For some patients in a bad ward, they might even be a bribe to ensure better treatment.

Certain excellent units with a high mortality rate might get little in the way of gifts: you tend not to give sweets to the staff when your wife has just died in ICU, for example. And who gives boxes of chocolates to dieticians?

There are further confounding factors. Once it becomes common knowledge that wards are judged by the number of gifts they receive, many patients will feel obliged to give something to avoid the nurses being penalised - even if the food was inedible and the ward filthy. It will become like tipping in restaurants: something you feel you have to do, even if you don't really want to.

Far from being a sensible measure of patient satisfaction, the chocolate box index is about as inept, unreliable and irrelevant a measure of professional competence as could be devised. Indeed, all surrogate methods of assessing professional behaviour are just that - surrogates.

So what's the point of collecting statistics like this if you can't utilise them, because they don't measure what you need to know? There is no known method of measuring 'the good practitioner' other than by personal assessment from colleagues - so why do managers insist on trying?

Mind you, there's one more aspect of the chocolate box index, one which happened to a nursing friend who works with cardiac patients. Her job is to teach patients to reduce their future coronary risk by eating well (all that veg), taking exercise, relaxing, giving up junk food and losing weight.

For Christmas her manager gave her a tin of chocolates. On a cardiac unit, it's not clear whether this should be regarded as an expression of thanks or attempted murder.

- Dr Lancelot is a GP from Lancashire. Email him at GPcolumnists@haynet.com.

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